| NPI | 1891972139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IN 71004862A) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3010032) |
| Enumeration Date | 2008-01-29 |
| Last Update Date | 2016-05-06 |